Home / Ambulatory Care Manager - Care Connections

Ambulatory Care Manager - Care Connections


At Lancaster General Health, our culture is what sets us apart and creates a lasting impression of our health system in the community and in the hearts of our patients and their families. A role with us is more than just a job, we ask that you Live Your Legacy at LGH by finding your passion in your everyday role, committing to those you serve, and reaching for your personal best.

We are recognized as 1 of only 9 hospitals in the entire country with awards in Medicare.Gov, LEAPFROG and Healthgrades Americas 50 Best Hospitals. We have attained five year Magnet ® recognition status for the fifth time with the American Nurses’ Credentialing Center (ANCC) and we are the 2018 recipient of the Foster G. McGaw Prize in recognition of the commitment to community service.

PENN MEDICINE LANCASTER GENERAL HEALTH offers a comprehensive benefits package:

We believe that the best care for our patients starts with the best care for our employees. Our employee benefits programs help our employees get healthy and stay healthy. We offer a comprehensive compensation and benefits program so that our employees can stay actively engaged and committed to living their legacy every day. Together, we will continue to make medical advances that help people live longer, healthier lives.

Join us and be part of a team that empowers you to do more than your job and encourages you to:

Live Your Passion. Live Your Best. Live Your Commitment. Live Your Legacy.

Summary

This position is for a Social Worker for the Care Connections program. Position is a .8 FTE, 32 hour/week position. Follows LGHP holiday schedule. On-call rotation approximately every 6 weeks. Candidate should have strong background in mental health/behavioral health assessment and referral, community resources, and providing support to high-risk patients. Candidate must hold Master of Social Work (MSW) degree.

Job Description

Position is in Lancaster, PA

Position may require occasional visits to patients in their home.

ATTENTION: Please be aware that, if you are an external applicant, you may need to complete an online assessment as part of the hiring process. This assessment will be sent to the e-mail address that you included in your application. Please note: Some e-mail accounts may receive the assessment e-mail in their junk/spam e-mail. This assessment must be completed within 5 days of receiving it. For more information regarding the assessment, please click HERE.

HOURS:  Fulltime; 64 hours/2 weeks, primarily dayshift hours.  On-Call Rotation.

SUMMARY: Will provide support to physicians, clinical staff and patients who fall under the auspices of the practice Medical Home Program. Uses an explicit process to identify patients at risk for poor outcomes, and who coordinates care and support, both within and outside of Community Health Services.

FUNCTIONS:

  • In conjunction with the practice team, identify patients at risk for poor outcomes or experiencing poor coordination of services who would benefit from more intensive follow-up.
  • Provide proactive outreach to patients to include telephonic, internet or face-to-face encounters.
  • Complete a comprehensive assessment of biopsychosocial, cultural and language support and self-management support needs.
  • Provide coordination with and act as liaison to hospital, long-term care, specialty, home health services, referrals, screenings and tests for care-managed patients.
  • Assist patients in problem-solving potential issues related to the health care system, financial and psychological barriers.
  • Be the system navigator and provide direct point of contact access for patient and family questions and concerns.
  • Ensure open communication regarding patient interactions with physicians and office staff.
  • Arrange referrals, screenings and test procedures.
  • Screen and refer as appropriate for depression and other psychological needs.
  • Maintain ongoing appropriate documentation on care coordination to promote team awareness, ensure patient safety, and follow through.
  • Assume advocate role on patient’s behalf with carriers to ensure approval of necessary supplies/services for patient in a timely fashion.
  • Identify and utilize cultural and community resources; establish and maintain relationship with identified service providers.
  • Provide medication management, including medication reconciliation and making recommendations to primary care provider for medication changes based on evidence-based protocols.
  • Provide chronic disease and self-management education and support.
  • Works closely with their assigned primary care practices to offer an individualized assistance with improving and maintaining quality patient care.
  • Oversees and guides the development of multiple health partnerships to achieve a positive e health effect.
  • Manages rising and high-risk patient, including management of patients with multiple co-morbidities or high risk for readmissions to hospital setting, using a care management platform/analytics.
  • Analyzes data to identify under/over utilization; improve resource consumption; promotes potential reduction in cost and enhances quality of care consistent with organization strategic goals and objectives.  Data includes but is not limited to predictive analytics, risk stratification, cost-benefit analysis, financial analysis, clinical outcomes; utilization and practice patterns.
  • As RN primary role of regional team will lead in facilitating transitions and referrals within the LGH health system as well as working with payors to refer appropriately to programs
  • Computer skills-utilization of EPIC, Excel, outlook, Microsoft word , intranet, etc.
  •   Attends periodic educational functions/conferences to enhance program knowledge.

REQUIREMENTS:

  • Social Worker:  Master’s degree in Social Work (MSW) from an accredited school or program.
  • Three (3) years of social work experience is required.
  • Excellent verbal and written communication skills.
  • Excellent Customer service skills.
  • Proven informal leadership skills.
  • Ability to work independently, setting priorities to coordinate care plans efficiently.
  • Ability to work effectively in a fast-paced team environment.
  • Highly organized and detail-oriented with the ability to perform multiple tasks simultaneously.
  • Effective behavioral and educational strategies, including, but not limited to: Motivational interviewing, teach-back method and self-management support.
  • Knowledge of Utilization review or managed care is preferred.
  • Licensure with Commission for Case Managers (CCM), or expected to obtain within two (2) years of employment

Benefits of Joining Penn Medicine Lancaster General Health:

PENN MEDICINE LANCASTER GENERAL HEALTH combines a Nationally Ranked Hospital with great schools, safe neighborhoods, affordable housing, local community events and festivals as well as a wealth of cultural and recreational activities. The scenic Susquehanna River Valley provides opportunities for fishing, skiing, kayaking, hiking and mountain biking in addition to easy access to NJ shoreline or Delaware beaches. Urban life is easily accessible, with New York, Baltimore, Philadelphia and Washington D.C. a train ride away. Local universities, Fulton Theatre, the downtown shopping and dining district and local sports teams make Lancaster a great place to Live, Work and Play.

Disclaimer

PENN MEDICINE LANCASTER GENERAL HEALTH is an Equal Opportunity Employer, committed to hiring a diverse workforce. All openings will be filled based on qualifications without regard to race, color, sex, sexual orientation, gender identity, national origin, marital status, veteran status, disability, age, religion or any other classification protected by law.

 

Search Firm Representatives please read carefully: PENN MEDICINE LANCASTER GENERAL HEALTH is not seeking assistance or accepting unsolicited resumes from search firms for this employment opportunity. Regardless of past practice, all resumes submitted by search firms to any employee at PENN MEDICINE LANCASTER GENERAL HEALTH via-email, the Internet or directly to hiring managers at Penn Medicine Lancaster General Health in any form without a valid written search agreement in place for that position will be deemed the sole property of PENN MEDICINE LANCASTER GENERAL HEALTH, and no fee will be paid in the event the candidate is hired by PENN MEDICINE LANCASTER GENERAL HEALTH as a result of the referral or through other means.

LGH Full Time Posted on 11/22/2021